THUMB LOSS: CASE REPORT
A patient with thumb loss in her right hand with the distraction device in situ.
View from the palmar aspect with distractor in place.
Consolidation phase after distraction. Note the degree of thumb lengthening.
Palmar view after web space deepening.
Thumb loss can be extremely debilitating to the patient since the thumb contributes to around 40% of hand function. Restoration of thumb can be achieved by sacrifice of a toe and in patients not willing for toe sacrifice by metacarpal distraction if the metacarpal is still intact. Let us look at such a patient.
A 23 year old female patient came to us with an amputated thumb on right side as a result of machine injury. The amputated part was crushed at multiple levels so no replantation was not a choice. Her wound was therefore initially sewn up and she was then placed for reconstruction. On examination, the amputation level was just beyond the MCP joint of the thumb. She was given the option of reconstruction of thumb using the method of toe transfer but she was not ready to sacrifice a toe.
Alternatively, she was planned for thumb reconstruction using distraction osteogenesis of the thumb metacarpal informing her that this was quite a long process and would require considerable time and cooperation.
In the first stage, an external distractor was applied after an osteotomy was made in the thumb metacarpal. After the latent period of 5 days had elapsed, the device was activated and the patient taught to distract the bone segments on a daily basis lasting for 3 months. Next followed the period of consolidation after distraction was completed. Thereafter, bone grafting was planned because a check X-ray did not show appreciable bone growth.
The bone gap was filled up using a cortico-cancellous bone graft harvested from the iliac crest on right side using a miniplate and screws. A period of consolidation followed lasting for 6 weeks. The distraction device was then removed and physiotherapy started.
Lastly, deepening of the first web space was accomplished with the adductor insertion being placed at the base of the newly created web space. Physiotherapy was continued as before.
A smaller than normal newly created thumb which was fully functional and sensate was the outcome. She could hold a pen using her new thumb and with support from the other fingers able to write leading to immense patient satisfaction.
Distraction osteogenesis of the thumb can be a useful option in reconstruction of the thumb especially in patients not willing to sacrifice a toe and those who have an intact metacarpal. However, patients need to be educated that this form of reconstruction requires a lot of patience and cooperation on part of the patient with multiple surgical sittings. Sensations and functions are generally good if the procedure is performed in the proper way.
About the Author
Dr. Souvik Adhikari is a Consultant Cosmetic & Plastic Surgeon based in the city of Kolkata and is well known for his reconstructive and cosmetic surgery endeavors involving all aspects of the human body.